What antibiotics are suitable for a patient with Impaired renal function (IRF) on dialysis for a Urinary Tract Infection (UTI)?

From the Guidelines

For patients on dialysis with a urinary tract infection (UTI), levofloxacin (250-500mg every 48 hours) is a recommended antibiotic option, considering its efficacy and the need for dose adjustment in renal impairment, as suggested by the guidelines 1. When managing UTIs in dialysis patients, it's crucial to consider the antibiotic's pharmacokinetics and potential toxicity.

• First-line options include levofloxacin, with a dose adjustment to 250-500mg every 48 hours for patients with creatinine clearance <50 mL/min, as recommended by the guidelines 1.
• Another option is trimethoprim-sulfamethoxazole, which should be used at half the usual dose for patients with creatinine clearance 15-30 mL/min, and at half the dose or an alternative agent for those with creatinine clearance <15 mL/min, as indicated in the guidelines 1.
• The duration of therapy typically ranges from 7-14 days, depending on the severity of the infection.
• It's essential to consider local resistance patterns and, if available, culture results to guide therapy.
• Dosing adjustments are critical in dialysis patients to avoid drug accumulation and potential toxicity.
• For hemodialysis patients, timing antibiotics after dialysis sessions is vital for drugs that are dialyzable, such as levofloxacin, which should be administered after each dialysis session, as recommended in the guidelines 1.
• Regular monitoring for adverse effects is necessary, particularly for nephrotoxic agents, to preserve the limited remaining kidney function in dialysis patients.

From the FDA Drug Label

In patients with impairment of renal function the elimination kinetics of ampicillin and sulbactam are similarly affected, hence the ratio of one to the other will remain constant whatever the renal function The dose of ampicillin and sulbactam for injection in such patients should be administered less frequently in accordance with the usual practice for ampicillin and according to the following recommendations: TABLE 3 Ampicillin and Sulbactam for Injection Dosage Guide for Patients with Renal Impairment Creatinine Clearance(mL/min/1. 73m2) Ampicillin/Sulbactam Half-Life (Hours) Recommended Ampicillin and Sulbactam for Injection Dosage ≥30 1.5-3 g q 6h-q 8h 15-29 1.5-3 g q 12h 5-14 1.5-3 g q 24h

For a patient on dialysis with a UTI, Ampicillin/Sulbactam can be given, but the dose should be adjusted according to the patient's renal function.

• The recommended dosage is 1.5-3 g every 6-8 hours for patients with a creatinine clearance of ≥30 mL/min/1.73m2.
• For patients with a creatinine clearance of 15-29 mL/min/1.73m2, the recommended dosage is 1.5-3 g every 12 hours.
• For patients with a creatinine clearance of 5-14 mL/min/1.73m2, the recommended dosage is 1.5-3 g every 24 hours. It is essential to note that the total dose of sulbactam should not exceed 4 grams per day 2.

From the Research

Antibiotic Options for UTI in Patients on Dialysis

• The choice of antibiotic for a patient on dialysis with a UTI depends on various factors, including the type of infection, the causative organism, and the patient's specific risk factors 3.
• For complicated UTIs, guidelines recommend using antibiotics with a narrow spectrum of activity and minimal collateral damage to prevent the development of resistance and complications 3.
• Cefepime, a fourth-generation cephalosporin, has been shown to be effective in treating UTIs, including those caused by extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae 4, 5.
• Other antibiotic options for UTIs in patients on dialysis include:
  • Cefotaxime and sulbactam, which have been shown to be effective in treating UTIs, with a bacteriological cure rate of 86.5% and a clinical cure rate of 79.03% 6.
  • Ceftazidime-avibactam, which has been shown to be effective in treating complicated UTIs and complicated intra-abdominal infections, including those caused by multidrug-resistant Gram-negative bacteria 7.
  • Carbapenems, which are often used to treat UTIs caused by ESBL-producing Enterobacteriaceae, but may not be necessary in all cases, as cefepime has been shown to be comparable in effectiveness 5.

Considerations for Patients on Dialysis

• Patients on dialysis may require adjusted antibiotic dosing due to their impaired renal function 4, 6.
• The choice of antibiotic should take into account the patient's specific risk factors, such as the presence of a urinary tract catheter, and the potential for antibiotic resistance 3.
• Close monitoring of the patient's response to treatment and adjustment of the antibiotic regimen as needed is crucial to ensure effective treatment and prevent complications 3, 4, 6, 7, 5.